Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya

Abstract

BackgroundVoluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents.SettingWe present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya.MethodsWe used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period.ResultsThe total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267.ConclusionThe VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations.Electronic supplementary materialThe online version of this article (10.1186/s12981-018-0207-x) contains supplementary material, which is available to authorized users.

Cost Utility of Supporting Family-Based Care to Prevent HIV and Deaths among Orphaned and Separated Children in East Africa: A Markov Model–Based Simulation

“…Two studies estimated ICERs as low as US$6/QALY gained to provide economic school support (e.g., fees, books, uniforms) for orphan girls in Zimbabwe 33 and US$267/DALY averted through combined medical male circumcision with HIV education for street-connected youth in Kenya. 34 However, these studies differ in several key features from the OSCAR Health and Well-Being study, most notably in their frequency and duration of intervention delivery for a maximum of 3 y 33 or over 30 d during a one-off period 34 (v. daily family-based support for a median of 6.9 y among participants of the OSCAR cohort 15 ). Furthermore, our 10-y ICER estimates of $15,593 per HIV infection averted are comparable with those for daily PrEP implementation strategies targeted to adolescent males and females in SSA, which range from $5,723 to $67,970 per HIV infection averted over 10-y horizons, 35 as well as to longer-term community-based and combination HIV prevention packages for adults, which produce median ICER values up to $22,000/HIV infection averted.…”

Age targeting and scale-up of voluntary medical male circumcision in Mozambique

“…However, we did not assume any variation in VMMC unit cost by age group, which could result in different cost-effectiveness results if reaching certain age groups required additional resources [7]. While studies have assessed the cost of VMMC among youth [26], the cost of programs designed to increase the proportion of adult men coming in for circumcision [27], or the variation in VMMC unit costs by program scale, type of facility, and type of staff performing the procedure [28], none have provided direct comparative evidence of how the unit cost of VMMC varies by age. VMMC programs in the region have difficulty reaching men over age 20, and demand creation efforts such as radio spots, billboards, and musical events are directed towards this population.…”

High impact health service interventions for attainment of UHC in Africa: A systematic review

“…HIV/AIDS disease prevention interventions were similar to the late childhood age cohort. However, there were additional HIV/AIDS interventions for this age cohort and these included; Voluntary medical male circumcision [73], provision of oral PrEP ( [74], intravaginal rings [74], microbicide gels, SILCS diaphragms used in concert with gel [74], injectable PrEP, provision of dual PrEP (both oral and injectable PrEP) and condom use [64,65,75,76]. Malaria disease prevention interventions such ITNs, IRS, larviciding were effective in averting DALYs caused by malaria.…”

“…Highly active antiretroviral therapy with and without laboratory monitoring [62,63,68], injectable cabotegravir/rilpivirine in all people on ART [105] and co-morbidity and opportunistic infections treatment were effective curative interventions for HIV/AIDS. Lateral-flow urine lipoarabinomannan (LAM) with a standard for TB diagnosis in PLHIV [106], active case finding (ACF) for TB in household contacts of index smear-positive TB patients with Xpert MTB/RIF as a diagnostic tool [83], Xpert/LF-LAM diagnosis [107], DOTS for management of TB [25,73,81,82,108]. DOTS management of TB was family-based, community-based or facility-based.…”